Testicular Necrosis Secondary to Incarcerated Inguinal Hernia in Male Infants. Own Observations

Abstract One of the possible consequences of incarcerated inguinal hernia in boys is testicular ischemia because of the prolonged compression of spermatic cord structures by the sac contents, resulting in ipsilateral testicular atrophy. This complication is well described in the literature and occurs in 5-34% of patients. The incidence of testicular atrophy secondary to incarcerated hernia is estimated to be 2-3%. Testicular necrosis as the result of hernia incarceration is, however, an extremely rare clinical setting. We present 4 male infants aged 3-10 weeks with inguinal hernia incarceration which led to ipsilateral testicular loss. All the boys had to be operated on because of irreducible incarcerated hernia and in all the cases testicular necrosis was found intraoperatively. The time of incarceration before surgical intervention ranged from 4 to 12 hours (mean 6.75). Our data show that every case of hernia incarceration in a very young male infant requires rapid diagnosis and proper intervention, i.e. surgical treatment, instead of repeated attempts of manual reduction. Ultrasound examination should estimate not only blood flow through the incarcerated intestinal loop, but also through the ipsilateral testis. Moreover, during the operation of the incarcerated hernia in a boy it is necessary to estimate the ipsilateral testis.


INTRODUCTION
Inguinal hernia in children is one of the most common congenital disorders managed by pediatricians and pediatric surgeons. Inguinal hernia repair is also one of the most common operations performed by pediatric surgeons. e main etiological factor for hernia development in children is prolonged patency of processus vaginalis, therefore indirect inguinal hernia occurs almost exclusively (in about 99% of all cases). In the general pediatric population the overall incidence of inguinal hernia is estimated at approximately 3% to 5%.
Because processus vaginalis plays an important role in testicular descent, male children with hernias outnumber females by an 8:1 to 10:1 ratio [1,2,3,4]. e most serious complication of inguinal hernia is its incarceration. e risk for hernia incarceration is the highest in children less than 1 year old (70% of cases) and decreases with age. Younger age and as well as prematurity are attributed as a risk factor for incarceration [1,2,3,4].
One of the possible consequences of incarcerated inguinal hernia in boys is testicular ischemia as a result of prolonged spermatic cord structure compression [1,5,6,7,8].
e aim of this study is to present a case series of male infants with testicular necrosis and its loss as a complication of incarcerated inguinal hernia.

MATERIAL AND METHODS
Over the last year 4 boys aged 3, 4, 5 and 10 weeks were diagnosed with irreducible incarcerated inguinal hernia and referred for urgent surgery. A er the diagnosis of hernia incarceration at least one attempt to reduce the hernia manually was made. e clinical data of the patients are presented in Table I.
In all the boys ultrasound (US) was performed a er the recognition of hernia incarceration, although in every case blood ow was checked only within the incarcerated bowel loop. e US revealed the presence of an incarcerated bowel loop within the inguinal canal. In 2 boys enlargement of the ipsilateral testis was diagnosed: in one there was slightly abnormal testicular echogenicity, in the other normal testicular structure. In the third case slight enlargement of the testis was found, with an abnormal structure, but there was visible blood ow, while in the last one the testis was described as completely normal. Only in one out of the 4 cases was there estimated blood ow through the testis (Figure 1). nieznacznie powiększone lewe jądro, nieprawidłowa struktura jądra, widoczny przepływ krwi przez jądro. Table II presents the details of operative ndings, as well as details of applied surgical management. Intraoperatively testicular necrosis with no torsion of spermatic cord structures was found in all 4 boys, despite an incarcerated bowel loop (Figure 2). In 3 the incarcerated intestinal loop estimated as viable was reduced, in the remaining 4 th patient bowel resection with primary anastomosis was necessary, because of concomitant bowel necrosis. As the attempts of revascularization of the testes by their warming and local lidocaine injection were ine ective (Figure 3), orchiectomy was performed in all the patients. e postoperative course was uneventful and the patients were discharged home 3 to 6 days a er surgery.

DISCUSSION
e vascular supply to the testis may be compromised by the incarcerated bowel, resulting in ischemia of the ipsilateral testis. e possibility of such testicular injury during inguinal hernia incarceration is a known clinical entity with reported occurrence of testicular ischemia from 5 to 34% [1,5,6,7,8,9]. Prolonged testicular ischemia can nally result in testicular atrophy. e reported incidence of this complication is 2 to 3% [1, 2, 5, 6, 7, 8].  Within an incarcerated hernia which undergoes operative treatment, the testis of the a ected side is usually found to be edematous and also somewhat cyanotic. Generally, unless the gonad is frankly necrotic, it is postulated to preserve the testis. In such cases the parents of each boy should be informed about the possibility of testicular diminishing and atrophy in the future [1,2,5,6].
In most of the published reports it is stated that testicular injury was not anticipated but was incidentally found during the operation. All the cases described referred to boys who required emergency operations because of an irreducible hernia. Moreover, testicular injury was typically noted in very young male infants, usually less than 3 months of age. All of our patients were also within the rst 3 months of their lives (the oldest one was 10 weeks) and all were referred for urgent surgery because of irreducible incarcerated inguinal hernias.
To date we have not found a similar case series presented in the literature. We were able to nd only two similar single cases, including one with necrosis of an undescended testis by an incarcerated hernia [21,22].

CONCLUSIONS
Our observations con rm that the reduction of the incarcerated inguinal hernia should be performed as early as possible, not only to preserve the bowel, but also to avoid excess pressure on the spermatic cord structures with possible testicular injury. On the other hand it seems that incarceration in a very young male infant requires proper intervention, i.e. operative treatment instead of repeated attempts of manual reduction, so as to avoid additional injury to the testis. It is also worth emphasizing that the initial ultrasound examination should estimate not only blood ow through the incarcerated inguinal loop, but also through the ipsilateral testis. During the operation of an incarcerated hernia in a boy it is necessary to estimate the ipsilateral testis.